Basic Information
| Provider Information | |||||||||
| NPI: | 1073575460 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GROSSO | ||||||||
| FirstName: | MEGAN | ||||||||
| MiddleName: | M | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | PA | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | TURCO | ||||||||
| OtherFirstName: | MEGAN | ||||||||
| OtherMiddleName: | M | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | PT | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 90 PRESIDENTIAL PLZ | ||||||||
| Address2: | 4TH FLOOR | ||||||||
| City: | SYRACUSE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 132022240 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3154644243 | ||||||||
| FaxNumber: | 3154645350 | ||||||||
| Practice Location | |||||||||
| Address1: | 90 PRESIDENTIAL PLZ | ||||||||
| Address2: | 4TH FLOOR | ||||||||
| City: | SYRACUSE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 132022240 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3154644243 | ||||||||
| FaxNumber: | 3154645350 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/03/2006 | ||||||||
| LastUpdateDate: | 05/06/2010 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
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| AuthorizedOfficialNameSuffix: | |||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 011709 | NY | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 02877383 | 05 | NY | MEDICAID |